Abstract
When pancreatic head cancer invades the superior mesenteric artery (SMA), attempts at curative resection are aborted. Preoperative imaging diagnostics to determine the surgical curability have yet to surpass the intraoperative information acquired via inspection, palpation, and trial dissection. Pancreatoduodenectomy (PD) is a standard measure for treating periampullary cancers. In conventional PD, SMA invasion is usually identified by dissecting the retroportal lamina, which connects the uncinate process and SMA nerve plexus after dividing the neck of the pancreas. During PD for pancreatic head cancer, this retroperitoneal margin frequently vitiates surgical curability. SMA-first approaches during PD are methods where the SMA is dissected first by severing the posterior pancreatic capsule to assess the SMA involvement of pancreatic cancer early in the operation. The first report of such an approach prompted subsequent reports of various maneuvers that are now known collectively as “artery-first” approaches. We herein review those approaches by classifying them according to (1) the side of the mesocolon from where the SMA approach occurs (supracolic or infracolic) and (2) the direction of access (right or left and anterior or posterior). The steps of the reported PD procedures are numbered according to a timeline and summarized using anatomical division of the SMA.
Similar content being viewed by others
References
Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. N Engl J Med. 2003;349(22):2117–27.
Gockel I, Domeyer M, Wolloscheck T, Konerding MA, Junginger T. Resection of the mesopancreas (RMP). a new surgical classification of a known anatomical space. World J Surg Oncol 2007;5:44.
Agrawal MK, Thakur DS, Somashekar U, Chandrakar SK, Sharma D. Mesopancreas: myth or reality? JOP. 2010;11(3):230–3.
Delpero JR, Bachellier P, Regenet N, Le Treut YP, Paye F, et al. Pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: a French multicentre prospective evaluation of resection margins in 150 evaluable specimens. HPB (Oxford). 2014;16(1):20–33.
Pessaux P, Varma D, Arnaud JP. Pancreaticoduodenectomy: superior mesenteric artery first approach. J Gastrointest Surg. 2006;10(4):607–11.
Ohigashi H, Ishikawa O, Eguchi H, Yamada T, Sakaki Y, Noura S, et al. Early ligation of the inferior pancreatoduodenal artery to reduce blood loss during pancreaticoduodenectomy. Hepatogastroenterol. 2004;51:4–5.
Varty PP, Yamamoto H, Farges O, Belghiti J, Sauvanet A. Early retropancreatic dissection during pancreaticoduodenectomy. Am J Surg. 2005;189(4):488–91.
Popescu I, David L, Dumitra A, Dorobantu B. The posterior approach in pancreaticoduodenectomy: preliminary results. Hepatogastroenterol. 2007;54:921–6.
Shah OJ, Gagloo MA, Khan IJ, Ahmad R, Bano S. Pancreaticoduodenectomy: a comparison of superior approach with classical Whipple's technique. Hepatob. Pancreatic Dis. Int. 2013;12(2):196–203.
Zimmitti G, Manzoni A, Addeo P, Garatti M, Zaniboni A, Bachellier P, et al. Laparoscopic pancreatoduodenectomy with superior mesenteric artery-first approach and pancreatogastrostomy assisted by mini-laparotomy. Surg Endosc. 2016;30(4):1670–1.
Nakao A, Takagi H. Isolated pancreatectomy for pancreatic head carcinoma using catheter bypass of the portal vein. Hepatogastroenterol. 1993;40:426–8.
Horiguchi A, Ishihara S, Ito M, Nagata H, Shimizu T, Furusawa K, et al. Pancreatoduodenectomy in which dissection of the efferent arteries of the head of the pancreas is performed first. J Hepatobiliary Pancreat Sci. 2007;14:575–8.
Weitz J, Rahbari N, Koch M, Buchler MW. The "artery first" approach for resection of pancreatic head cancer. J Am Coll Surg. 2010;210(2):e1–4.
Mizuno S, Isaji S, Tanemura A, Kishiwada M, Murata Y, Azumi Y, et al. Anterior approach to the superior mesenteric artery by using nerve plexus hanging maneuver for borderline resectable pancreatic head carcinoma. J Gastrointest Surg. 2014;18(6):1209–15.
Zhang Y, Sun D, Chen X. The uncinate process first approach in laparoscopic pancreaticoduodenectomy; a single-institution experience. Surg Laparosc Endsc Percutan Tech. 2017;27:4.
Inoue Y, Saiura A, Yoshioka R, Ono Y, Takahashi M, Arita J, et al. Pancreatoduodenectomy with systematic mesopancreas dissection using a supracolic anterior artery-first approach. Ann Surg. 2015;262(6):1092–101.
Zhu J, Han D, Li X, Pan F, Ma J, Kou J, Fan H, et al. Inferior infracolic 'superior mesenteric artery first' approach with a no-touch isolation surgical technique in patients with a borderline resectable cancer of the pancreatic head. Ann Surg Oncol. 2016;23(Suppl 5):976–80.
Shukla PJ, Barreto G, Pandey D, Kanitkar G, Nadkarni MS, Neve R, et al. Modification in the technique of pancreaticoduodenectomy; supracolic division of jejunum to facilitate uncinate process dissection. Hepatogastroenterol. 2007;54:1728–30.
Hackert T, Werner J, Weitz J, Schmidt J, Buchler MW. Uncinate process first–a novel approach for pancreatic head resection. Langenbecks Arch Surg. 2010;395(8):1161–4.
Kurosaki I, Minagawa M, Takano K, Hatakeyama K. Left posterior approach to the superior mesenteric vascular pedicle in pancreaticoduodenectomy for cancer of the pancreatic head. JOP. 2011;12(3):220–9.
Kawabata Y, Tanaka T, Nishi T, Monma H, Yano S, Tajima Y. Appraisal of a total meso-pancreatoduodenum excision with pancreaticoduodenectomy for pancreatic head carcinoma. Eur J Surg Oncol. 2012;38(7):574–9.
Jackson BB. An approach to stenotic lesions of the proximal superior mesenteric artery. Am J Surg. 1962;104:86–8.
Stoney RJ, Ehrenfeld WK, Wylie EJ. Revascularization methods in chronic visceral ischemia caused by atherosclerosis. Ann Surg. 1977;186(4):468–76.
Paturet J. Traite d'anatomie humaine, vol. 3. Paris: Masson Editeur; 1958.
Hivet M, Lagadec B, Poilleux J. Chirurgie des arteres digestives. France; 1970.
Michels NA. Blood supply and anatomy of the upper abdominal organs with a descriptive atlas. Philadelphia: Lippincott; 1955.
Suzuki T, Nakayasu A, Kawabe K, Takeda H, Honjo I. Surgical significance of anatomic variatiow of the hepatic artery. Am J Surg. 1971;122:505–12.
Pedziwiatr M, Pisarska M, Malczak P, Major P, Wierdak M, Radkowiak D, et al. Laparoscopic uncinate process first pancreatoduodenectomy-feasibility study of a modified 'artery first' approach to pancreatic head cancer. Langenbecks Arch Surg. 2017;402(6):917–23.
Vallance AE, Young AL, Pandanaboyana S, Lodge JP, Smith AM. Posterior superior mesenteric artery first dissection versus classical approach in pancreaticoduodenectomy: outcomes of a case-matched study. Pancreas. 2017;46(2):276–81.
Zhou HY, Wang Y, Zhang J, Ruan CP, Wang WJ, Sun YP, et al. Retrograde vs conventional dissection technique in pancreaticoduodenectomy: a pilot study. JAMA Surg. 2014;149(6):604–7.
Sanjay P, Takaori K, Govil S, Shrikhande SV, Windsor JA. 'Artery-first' approaches to pancreatoduodenectomy. Br J Surg. 2012;99(8):1027–35.
Dumitrascu T, David L, Popescu I. Posterior versus standard approach in pancreatoduodenectomy: a case-match study. Langenbecks Arch Surg. 2010;395(6):677–84.
Ironside N, Brenner D, Heyer E, Chen CJ, Robison T, Christophe B, et al. Systematic review and meta-analysis of perioperative and long-term outcomes in patients receiving statin therapy before carotid endarterectomy. Acta Neurochir (Wien). 2018;160(9):1761–71.
Negoi I, Hostiuc S, Runcanu A, Negoi RI, Beuran M. Superior mesenteric artery first approach versus standard pancreaticoduodenectomy: a systematic review and meta-analysis. Hepatobiliary Pancreatic Dis. Int. 2017;16(2):127–38.
Neoptolemos JP, Stocken DD, Dunn JA, Almond J, Beger HG, Pederzoli P, et al. Influence of resection margins on survival for patients with pancreatic cancer treated by adjuvant chemoradiation and/or chemotherapy in the ESPAC-1 randomized controlled trial. Ann Surg. 2001;234(6):758–68.
Luttges J, Vogel I, Menke M, Henne-Bruns D, Kremer B, Kloppel G. The retroperitoneal resection margin and vessel involvement are important factors determining survival after pancreaticoduodenectomy for ductal adenocarcinoma of the head of the pancreas. Virchows Arch. 1998;433(3):237–42.
Pessaux P, Marzano E, Rosso E. A plea for the artery-first dissection during pancreaticoduodenectomy. J Am Coll Surg. 2010;211(1):142–3.
Pessaux P, Rosso E, Panaro F, Marzano E, Oussoultzoglou E, Bachellier P, et al. Preliminary experience with the hanging maneuver for pancreaticoduodenectomy. Eur J Surg Oncol. 2009;35(9):1006–100.
Borrelly J. Abord sus-mesocolique droit de l'artere mesenterique superieure a son origine. J Chir. 1973;105(2):167–70.
Bonnichon P, Rossat-Mignod JC, Corlieu P, Aron C, Yandza T, Chapuis Y. Surgical approach to the superior mesenteric artery by the Kocher Maneuver: anatomy study and clinical applications. Ann Vasc Surg. 1986;4:505–8.
Hirono S, Kawai M, Okada KI, Fujii T, Sho M, Satoi S, et al. MAPLE-PD trial (mesenteric approach vs. conventional approach for pancreatic cancer during pancreaticoduodenectomy): study protocol for a multicenter randomized controlled trial of 354 patients with pancreatic ductal adenocarcinoma. Trials. 2018;19(1):613.
Author information
Authors and Affiliations
Contributions
All authors meet the International Committee of Medical Journal Editors authorship criteria.
Corresponding author
Ethics declarations
Conflict of interest
Junji Yamamoto and other co-authors have no conflict of interest.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Yamamoto, J., Kudo, H., Kyoden, Y. et al. An anatomical review of various superior mesenteric artery-first approaches during pancreatoduodenectomy for pancreatic cancer. Surg Today 51, 872–879 (2021). https://doi.org/10.1007/s00595-020-02150-z
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00595-020-02150-z